Nokea
The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?
- A. Hand rolls
- B. A trapeze bar
- C. A trochanter roll
- D. Hand-wrist splints
Correct Answer: C
Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.
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While a client is receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?
- A. Monitor the client's blood glucose level every 4 hours.
- B. Change the TPN tubing every 72 hours.
- C. Weigh the client daily.
- D. Change the TPN bag every 24 hours.
Correct Answer: D
Rationale: The correct action is to change the TPN bag every 24 hours to reduce the risk of infection. Changing the TPN tubing every 72 hours (Choice B) may increase the risk of contamination. Monitoring the client's blood glucose level every 4 hours (Choice A) is important but not specific to TPN administration. Weighing the client daily (Choice C) is essential for monitoring fluid status but is not directly related to TPN administration.
A client with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: Contact precautions are necessary when performing postmortem care on a client with MRSA to prevent the spread of infection. Contact precautions involve using barriers like gloves and gowns to limit direct contact with the deceased individual's body fluids and tissues. Airborne precautions are used for pathogens that are transmitted through the air, like tuberculosis. Droplet precautions are for pathogens that are transmitted through respiratory droplets, such as influenza. Compromised host precautions are not a recognized standard precaution type and are not applicable in this scenario.
A client with a history of heart failure is admitted with weight gain and peripheral edema. Which medication should the LPN/LVN anticipate being prescribed?
- A. Lisinopril (Zestril)
- B. Furosemide (Lasix)
- C. Metoprolol (Lopressor)
- D. Simvastatin (Zocor)
Correct Answer: B
Rationale: Furosemide (Lasix) is the correct answer. In a client with heart failure experiencing weight gain and peripheral edema, the priority is to manage fluid overload. Furosemide is a loop diuretic commonly prescribed to reduce excess fluid in heart failure patients. Lisinopril (Zestril) is an ACE inhibitor used to treat hypertension and heart failure but does not directly address fluid overload. Metoprolol (Lopressor) is a beta-blocker that helps manage heart failure symptoms but does not primarily target fluid retention. Simvastatin (Zocor) is a statin used to lower cholesterol levels and is not indicated for managing fluid overload in heart failure.
A client is experiencing dyspnea and fatigue after completing morning care. Which of the following actions should the nurse include in the client's plan of care?
- A. Schedule rest periods during morning care.
- B. Discontinue morning care for 2 days.
- C. Perform all care as quickly as possible.
- D. Ask a family member to come in to bathe the client.
Correct Answer: A
Rationale: Scheduling rest periods during morning care is essential for managing dyspnea and fatigue in the client. This approach allows the client to pace themselves and catch their breath, promoting comfort and reducing symptoms. It is crucial to provide breaks to prevent overwhelming the client and exacerbating their symptoms. Discontinuing morning care for 2 days (choice B) is not a suitable solution as it does not address the underlying issue and may lead to neglect of essential care. Performing all care as quickly as possible (choice C) can worsen the client's symptoms and compromise their well-being by increasing stress and exertion. Asking a family member to bathe the client (choice D) does not address the need for rest periods during care and may not be feasible or appropriate in all situations.
When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?
- A. Bleeding time
- B. Coagulation time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: C
Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.